Academic journal article Journal of Eating Disorders

Thinking about Internal States, a Qualitative Investigation into Metacognitions in Women with Eating Disorders

Academic journal article Journal of Eating Disorders

Thinking about Internal States, a Qualitative Investigation into Metacognitions in Women with Eating Disorders

Article excerpt

Author(s): Alix Vann[sup.1], Esben Strodl[sup.1] and Erin Anderson[sup.2]


Given that eating disorders (EDs) are prevalent among women in western countries [1, 2], there is an obvious need to develop effective interventions for eating disorders. Psychological therapies have been recommended as important components of interventions for EDs, with cognitive behaviour therapy (CBT) being a commonly recommended treatment [3, 4]. While CBT has been helpful for many people, there are still limitations in its effectiveness. For example, meta-analyses have found that only approximately 41% of individuals with Bulimia Nervosa (BN) completing individual CBT interventions recover and only 29% remain recovered 12 months following CBT [5].

Given the variable and often limited impact of diagnosis-specific treatments for EDs, as well a recognition of additional maintaining mechanisms beyond the common cognitive targets of overvaluation and dieting, an enhanced cognitive behaviour therapy (CBT-E) was developed for EDs by Fairburn and colleagues [6, 7]. This enhanced therapy was based on a proposed transdiagnostic cognitive model of EDs as well as the inclusion of four additional maintaining mechanisms: perfectionism, core low self-esteem, mood intolerance, and interpersonal difficulties. While Christopher Fairburn's CBT-E has significantly improved the conceptualisation of eating disorders, trials using CBT-E indicate that there is still a need to further refine the case formulations and interventions for EDs. For example, in a sample of 154 patients with an EDs other than Anorexia Nervosa (AN), after receiving 20 weeks of CBT-E only approximately 50% of the sample had a level of eating disorder features less than one standard deviation above the community mean [7].

While such outcomes are still admirable given the complexity and pathology associated with EDs, these findings have resulted in calls by clinicians and researchers to further develop the cognitive models that underpin interventions for EDs [8, 9]. One proposition has been to extend the standard cognitive therapy conceptualisation of focusing on the content of cognitions, or what people think, to how people think [10, 11]. The domain of 'how' thinking occurs comprises the concept of metacognition, which refers to the cognitive mechanisms involved in the knowledge, interpretation and regulation of thinking itself [10]. One metacognitive theory has stemmed from the Self-Regulatory Executive Function (S-REF) theory of psychological disorder proposed by Adrian Wells [12]. The S-REF model suggests that beliefs comprise two metacognitive components that guide information processing, interpretations and the control of thoughts. The first is metacognitive knowledge, or the positive and negative beliefs which an individual holds about how to regulate internal states. The second is metacognitive regulation, or the coping strategies and changes in focus of attention that result from the chosen means of internal regulation [12]. S-REF theory suggests that in the case of psychological disorder, this metacognitive system becomes dysfunctional and the metacognitive processes become maladaptive [12], resulting in a Cognitive-Attentional Syndrome (CAS) [11, 12]. The CAS involves perseverative thinking and excessive conceptual processing, as well as attentional hypervigilance to threat, which lead to the use of unhelpful coping strategies that ultimately fail [10, 12].

Metacognitive theory has previously been applied in the conceptualisation and treatment of anxiety and depression with success [12, 13]. However, the application to EDs has been limited thus far, with integrated cognitive and metacognitive therapy used only with BN [8]. This is perhaps due, in part, to the current lack of a sound metacognitive model of EDs that specifies which metacognitions underlie EDs, and are therefore important to target. The limited application of metacognitive theory in EDs may also reflect the reliance on deductive research methodologies by employing quantitative measures of metacognition that were developed for other psychological disorders [14, 15]. …

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